THE CURRENT MALAYSIAN HEALTHCARE SYSTEM - A BRIEF REVIEW

This article will form the first of 3 articles on the present Malaysian healthcare system, and the recently proposed healthcare reform. The articles are targetted for the STAR newspaper over the next 3 sundays, under "Fit for Life ".

Introduction

Our colonial masters, before the days of Merdeka, had bequeath to us a healthcare system which have served us well ( with some modifications ) till this day. Numerous WHO reports in the 90’s and this new millennium, have praised the Malaysian healthcare system. It is often quoted that any Malaysian ( or even non-citizens ), should they need medical attention anywhere in the country ( East or West Malaysia ), can go to the nearest health centre ( 81.1%of the population live within 3Km radius from a static health facility ), for free treatment ( and may I add, without the need to first show your insurance card, or wait for insurance coverage verification ). And should he need to be seen for further assessment, that can also be arranged and he could have up-to-date tertiary care treatment for almost no cost. How many countries in the world can boast of that, at this point in time?.

Currently we have a growing private healthcare system, running along side a public system. The public system, comprising the many public general hospitals, district hospitals, health clinics, mobile clinics and clinic desa. The public system also takes care of disease prevention, preventive health, environmental health, dental health, food and water quality control, enforcement of standards and oversee the private system. In the public system ( or what Mr Obama may call the public option ), treatment is given at almost no cost to minimal cost ( ranging from first class to third class ). This safety net is tremendous and provides a very important aspect of looking after our poor and needy. It would be a great lost, not to have this safety net. The private system is mainly a fee for service healthcare providing system, where those who are ill, seek medical treatment, either at the primary care level or at the secondary or tertiary care level. In the private system, it is fee for service and many pay out of pocket. There is an increasing trend for some to buy health insurance, either through their employer or on their own. There is some concern that over the last 10 years, the proportion of population seeking treatment in the private sector has increase, raising the private healthcare expenditure. This is sometimes used as a reason for trying to justify re-structuring the healthcare system.

The cost of health in Malaysia.

Health is a basic right of every and all individuals. It must not be denied to anyone, irrespective of race, colour, creed or economical status. Equitable healthcare must be available for all who need, Malaysians or non-Malaysians alike. The more touchy issue is, not equitable healthcare but also equitable and equal standard of care. Undoubtedly, those who can afford will get the standard of care that they are willing to pay for. Malaysia is after all a capitalist society where market forces play a part in healthcare delivery. Paying for quality medical care to get well is cost effective, but paying for frills in “ boutique “ hospitals, that is another issue. Maybe the more important question to ask is, have wasted our healthcare budget? Spending billions and getting poor national health in return? Have our healthcare spending, rising over the years, kept pace with inflation and rising cost of services in other sectors, or put in another way, are we over-spending in healthcare, to the detriment of other service sectors?

Let’s answer the first question. Have we wasted our healthcare budget? Did we spend the money budgeted wisely? Some facts and figures are in order. We spend ( so it is reported in the National Health Accounts ) in 2008, 3.6% of our GDP on healthcare. Of this, 2.1% was spend on public healthcare sector. In 2006, 7% of the overall government spending was on health. These numbers are not very large. And yet, for this small amount of money spend, we have the following health outcome data reported by the Ministry of Health in their report for 2008.

Population of Malaysia 27,728,700

Average Annual Population growth rate 2.0%

Infant Mortality Rate 6.3% per 1,000 live births

Maternal Mortality Rate 0.3% per 1,000 live births

Perinatal Mortality Rate 7.3% per 1,000 live births

Live expectancy at birth

Males 71.70 years

Females 76.46 years

I am very please to note that these facts are all in keeping with an almost developed country ( we are not yet 2020 ). Yes, they are not as good as UK ( spend 8% GDP on health ), or USA ( spend 16% of GDP on health ). We are spending 3.6% of GDP on health ( way below average for a developed country ) and scoring outcome data almost as good as the developed country. So far, it seems that the money have gone into good medical care.

Now to answer the second question, have we over-spend on healthcare to the detriment of other services sector? Have healthcare spending kept paced with inflation? The answer is an obvious NO, we have not overspend. Here, the figures are a bit more difficult to find. When I reviewed the National Health accounts ( NHA ), prior to 2007, they was little emphasis of the private healthcare expenditure. Let me illustrate. The 2007 NHA reported that the total expenditure on Health was 4.7% of GDP ( spend 44.8% by public sector and 45.2% by private sector ). In absolute terms, the total expenditure on health ( public and private ) was RM30.2 billion. Of which RM 13.3 billion was spend in the public sector and RM26.7 billion was spend in the private sector.

Prior to the 2007 NHA, the numbers were not reported this way. Let me make a simplify chart for you to understand. Remember, these are all data taken from the Ministry of Health facts ( 2005-2008 ), to illustrate important aspects of healthcare spending.

2006 2007

Population 27,173,600 27,728,700

Doc : pop ratio 1 : 1,145 1 ; 1,105

Total Health Budget RM 25.5 Billion RM 30.2 billion

Public RM 11.2 billion RM 13.3 billion

Private RM 14.3 billion RM 16.9billion

Total private clinics 2,992 6,371

Total doctors in private 9,440 10,006

If these numbers are too be believed, then we must conclude that between 2006-2007, the healthcare budget has increased by approximately18%, and the private healthcare expenditure had increased by approx. 18%. Yes, there are leakages and wastage in the healthcare delivery system. Healthcare in the public sector is still very good and very cost effective. It could be improved, I am sure. We will come to that later. Healthcare in the private sector is quite another story. By design in the private sector, doctors fees are controlled and mandated by law ( The Private Healthcare Facilities and Services Act 1998 and Regulations 2006 ). Any doctor found to have transgressed the fees schedule can be hauled up by the Ministry of Health. What is very surprising is that private hospital cost are not declared, to safeguard the public. If one should be unfortunate enough to fall ill, and be admitted to a private medical center, upon your recovery, you will find that the total hospitalization bill has two main components. There is the medical consultant’s fees ( which usually forms about 15-20% of the total bill, and it used to be 30% previously ), and the hospital bill. The medical consultant’s fees is declared in the Private Healthcare Facilities and Services Act 1998. Surprisingly, the hospital portion is not. Private hospitals ( almost all of which are owned by government linked companies ), do not have to declare to us how they charge. The private hospital cost can change by the month. I am told that the surcharge ( or mark-up ) on drugs or consummables on some items in private hospitals can vary from 20% to 200% ( on some chemotherapy items ). Some “ boutique “ hospitals justify this by saying that they are 6 or even 7 stars. Sad to say, “ boutique ness “ , does not contribute to medical care. It may add to the ambience and “poshness” but that is not medical care. How then do we factor this “ luxury factor “ into healthcare expenditure. Could the rising cost of private healthcare be significantly contributed to by these 6-7 star hospitals, who view it as a service hospitality business, where fees and charges are more on a profit margin basis? The Ministry of Health know this and yet have done little to curb it. In fact, they maybe tacitly encouraging it. We have brought this point up with the previous Minister of Health, but little have been done to try and have a fees schedule for private hospital treatment cost. Private hospitals are only prepared to declare their hospital bed charges, which is no reflection on the overall treatment cost. We even when as far as to suggest that the Ministry of Health charge first class wards full rates ( without government subsidy ), and allow 3^rd class free treatment. This will then set a benchmark for hospital charges for the private sector. Alas, this also fall on deaf ears. For many private hospitals, healthcare is a for profit business, and the authorities have allowed it to be so. Could this be a reason why private healthcare cost is rising, and more and more companies are getting into the private healthcare business?

The other reason maybe that many hospitals ( as part of their branding ) purchase “ high tech” equipment at tremendous cost ( millions of dollars ) and begin to ask consultants to use them, whether indicated ( marginally indicated ) or not. Every headache coming to emergency room, gets a CT scan ( ordered by a private hospital employed medical officer ), even before a medical consultant is consulted ( and this is in a tertiary care hospital ). There must be more CT scans and MRI scans in the Malaysia ( per 100,000 population ) then in USA. Very often, “high tech” equipment are abused for profit. It is only fair to say that not all private hospitals abuse their “high tech” investigative equipment, but many do. Afterall, the bottomline is profit.

Undoubtedly, it is true that with medical advance, the cost of keeping patients alive and well has also gone up. What with new modalities of investigations and assessments, and new modalities of treatment previously unheard of. It is universally accepted that with all the medical advances, we all live longer and better.

Conclusion

Looking at it overall, the Malaysian Healthcare system is one of the best in the world and aptly suited to our needs. Around the ASEAN region we easily boast one of the better healthcare delivery system. In fact many from the surrounding region come to Malaysia for their treatment for heart diseases, cancer treatments and even normal deliveries. There are many tertiary care centers spread all over the country to cater to the “rakyat’s “ needs. No one need to go all the way from Penang or Padang Besar for treatment of heart illnesses in Kuala Lumpur as there is a very good cardiac unit in Penang General Hospital. Similarly for heart patients from Kuching. They do not have to travel to Peninsular or Singapore ( as in the bygone days ). There is a state of art Cardiac Center in Kuching.

We have weathered the A H1N1 storm, the SARS storm, heart disease rates have come down, cancer patients survival and quality of life have improved. Palliative medicine and pain relieve for the terminally ill is now widely available. Stroke rehabilitation and orthopedic rehabilitation is so much more available. Minimally invasive surgery and even robotic surgery is being practice in Malaysia. We have a good system at the moment.

Yes, there are shortcomings. We shall next write about the shortcomings in the Malaysian Healthcare delivery system. Things could be so much better.

Although there is obviously much room for improvement, but shabas to the Ministry of Health for a job well done.

Dr Ng Swee Choon

FPMPAM

GSK REPLIES ; PLEASE WAIT FOR RECORD

Well, 1 week after the report from the US senate asking that Rosiglitazone ( Avandia ), be remove from use in USA, GSK replies in a 30 page white paper to the US senate. Basically, their reply is that GSK was forthcoming in all the information requested, and that the US senate maybe relying too much on the 2007 report by Dr Steve Nissen, whose conclusions were disputed by some experts. GSK is confident that the results of RECORD, due later this year, will show that Rosiglitazone is not associated with any increase incidence of heart attacks. I must say that looking on from here, it may be wise for GSK to volunteerily remove rosiglitazone from the market place. The adverse publicity would certainly affect sales, myself included. I doubt that one study, the RECORD, will safe Rosiglitazone.

IS THIS THE END OF GSK's AVANDIA?

Avandia is in the news again. On Friday, a US senate select committee was reviewing the evidence that Avandia ( Generic name : Rosiglitazone ), may be associated with an increase risk of heart attacks. This was highlighted in the Star papers today. This is actually a re-hash of the hooha that we had written earlier about the cardiac problems with avandia, way back in 2007.
Lets take a step backwards. Rosiglitazone belongs to a group of drugs called " insulin sensitisers ", that is widely used in the treatment of type 2 diabetics. The other member oif this group is Pioglitazone ( Actos ). Rosiglitazone is produced by GSK ( Glaxo Smith Kline ). When the initial clinical trial results came out in 2007, there was much media attention and also medical attention, firstly because GSK was not very forthcoming in releasing details of the trials and secondly because there seemed to be a real increase in heart attack rates and also heart failure rates in those taking rosiglitazone when compared to those taking sulphonlyureas. Of course, one of the crusaders raising this issue was Dr Steve Nissen of Cleveland Clinic fame.
Following the 2007 adverse publicity, the sales of Avandia dropped and GSK launched a promotional campaign to assure the medical community that rosiglitazones are safe but that we must exercise caution in selecting the right patient subset in the use of rosiglitazone. For some reason, FDA did approve the use of rosiglitazone in the treatment of type 2 diabetes, but did caution that it should not be used in patients with known history of heart failure.
I am not certain what spark this latest re-investigation into rosiglitazones. Looking at the problem 4 years later, it probably is true that rosiglitazone maybe assocaited with a silghtly higher risk of heart attacks and it is obviously contra-indicated in heart failure.
As clinicians, we should always play safe and where there is a choice, perhaps we should chose the safer option.

ONLY USE DRUGS WHEN THERE ARE CLEAR INDICATIONS. ONE OF THE PROBLEM WITH STATINS.

GONG XI FA CAI to one and all. I am back from my golfing.

The just published online edition of the Lancet, carried a very interesting study by the workers from Glasgow University. The paper by Dr Sattar N, Preiss D, Murray HM, et al. is entitled " Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010; DOI:10.1016/S0140-6736(09)61965-6". It is available at http://www.lancet.com. This is another of those electronic trials and online research of previous megatrails and also their meta-analysis of the results. Their aim was to see if there is any truth in the suspicion, made more obvious by the JUPITER trial, that the use of statins may be associated with a higher incidence of diabetes. We first saw this trend in the earlier statin trials but it was less pronounced. Dr Sattar and colleagues, researched 13 statin trials done in the nineties and two thousands, any witha followup of more then 1 year and with an enrollment of more then 1,000 patients. It had to be placebo controlled and they stidied those who were none diabtics at the start of the trial. What they found was that at an average of 4 years of followup, there was a 9% higher incidence of diabetes amongst those taking statins. The risk seemed to be higher the more potent the statins. In the Jupiter trial, the incidence of new onset diabetes was 18% higher at a mean follow-up of only 1.9 years. The risk was lowest with pravastatin. In fact the earlier WESCOP study did not show any increase in incidence of T2DM. To put it in perspective. the authors worked out that over 4 years follow-up, for every 255 patients treated with statins, you will see 1 case of new onset diabetes, and you will save 5.4 cases of MIs or death from heart disease. Meaning that on the balance, it is still worthwhile to use statins in secondary prevention of CAD. Well statins for primary prevention, that maybe a different story. I personally will not use statins liberally in pprimary prevention, unless that patient is at high risk and has failed life-style modification. When we use drugs without clear indication, we never know what awaits to haunt us later. This is a good example. In the nineties, we have no clue that statins maybe associated with new onset diabetes. We will not be doing our patients any favours by exchanging just a raise LDL-C level with a 9% chance of getting T2DM in the next 4 years. It may wiser to institute life style modification and discuss the risk of statins, before simply starting statins for just a raise LDL-C. We all learn, or dont we?

BILL CLINTON'S ANGIOPLASTY. UPDATES

Well, we are a little clearer now.
Mr Clinton was admitted to Columbus Presbyterian on Thursday when many of the "kingpin"interventionist were on route to Rome for the Joint Interventional Meeting 2010. So he had an intervention to his native left circumflex coronary artery, when his venous graft to the L Cx was occluded. The procedure was done by Dr Mark Apfelbaum and Dr Michael Collins.
We are all happy that Mr Clinton is well and discharged. We only hope that he will have an uneventful recovery and also good longterm results.

CORONARY ARTERY BYPASS SURGERY. EVEN WITH THE BEST

When I came into the office this morning, I learn that Mr Bill Clinton ( former US president ) had undergone angioplasty yesterday ( Thursday, 11th Feb 2010 ) at the New York Columbus Presbyterian Hospital. Two coronary stents were implanted. I presumed that they were drug eluting stents. I checked out all the usual websites, and few details of the procedure had been released. I know that he was probably unwell sometime on Sunday or Monday when he rang the NY Presb.Hospital chief of cardiology for an appointment, as he was experiencing chest pains. He was given an appointment in two days. But because of his heavy schedule, he was seen on Wedsnesday and had his angiogram and angioplasty of Thursday. Two stents were implanted in his native coronary artery as one of the venous graft had become stenosed. He took the procedure well and is now recuperating. Of course we all know that Columbus Presbyterain is a world reknown center for angioplasty, hosting the likes of Dr Greg Stone ( of Taxus fame ), Dr Antonio Colombo, Dr Martin Leon, Jeff Moses and many others. The staff interventional cardiology list in NY Presbyterian is like a whose who in interventional cardiology. Maybe that is why their cardio-surgical work is not ranked among the best in USA. I know that Dr Greg Stone was in Rome on Thursday ( probably with Antonion Colombo ), so they could have done the procedure. I really do not know who performed the angioplasty and which stents were used. It would have been nice to know.
It is important to note that Mr Clinton is a hypertensive and has raised lipids. In fact back in 2004, he was put on statins, which he stopped, and the statins were re-instituted, before his quadraple by-pass surgery ( back in 2004 ). There was alot of discussion then, whether stopping the statins had anything to do with his chest pains and unstable angina in 2004, for him to undergo emergency CABG by Dr Craig Smith. Be that as it may, 6 years after CABG, the venous grafts have blocked again, even in the land of the best for the best. He exercises ( 5 mile runs ) but eats the worse kind of diet for a heart disease patient, giant burgers, chips, steaks etc..
Well, I wish to highlight two points. Life style changes are a very important part of heart disease treatment and medical therapy, including the use of statins is very important. Also, re-vascularisation procedures are in many ways, buying time and they all ( whether CABG or angioplasty ) have their limitations and both procedure suffer from the issue of re-narrowing. We would have expected that the CABG ( on the average ) should have lasted 10-15 years. In Bill's case, it was just 6 years. Hopefully, of the 4 grafts inserted in 2004, only one was noarrowed at 6 years, which is the average. The other 3 are presumably healthy. Angioplasty with drug-eluting stents have a re-narrowing rate of < 5%. we always tell our patients that there is a high possibility that you may need a repeat angioplasty in 5-6 years time.
Well, we all wish Mr Bill Clinton a speedy recovery. He is a good campaigner and has done much to help the Haiti disaster.
PS. -
As we get more news, it seems that Mr Clinton was seen by his cardiologist ( wonder who ) on Thursday morning and taken straight to the cath. lab for his angiogram. The indication being recurrent chest pains. The coronary angiogram showed that his LIMA to LAD was fine ( the word used is "pristine"). One of the venous graft was totally occluded and the other two grafts were patent. The interventionist chose to treat the native artery supplied by the occluded venous graft with two DES. It is also noted that Mr Clinton was quite compliant with his diet following the CABG in 2004. He was actually kept on a South Florida diet, and was compliant. His cardiologist feels that he should be well enough for discharge on Friday.

GOOD BEHAVIOUR IS REWARDED. HELP YOUR HEART

As physicians, we must keep emphasizing the importance of lifestyle modification, in any situation that can help to maintain good health. The cliche that " Health is Wealth" cannot be overemphasized. You may like to know that even in such a severe lifethreatening disorder like acute coronary syndrome, life-style modification can show a difference in 6 months.
This fact was highlighted in a paper published in the Feb1 issue of circulation. The work is done by researchers in McMaster University, Hamilton, led by Dr Clara Chow. The paper is entitled, " Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes". Circulation 2010; 121:750-758. They studied 18,809 patients from 41 countries who were hospitalised and treated for acute cironary syndrome. Before discharge, the patients were all counselled regarding the importantce of lifestyle modification, including diet, exercise and stop smoking. At the 6 months followup re-evluation, they found that about 65 % had been compliant. One third never stopped smoking, and 30% never adhere to diet or exercise regimes. But of those who adhered to the regime of stop smoke, diet and exercise, there was a 50% less incidence of heart attacks, strokes and death. What they also discovered was that patients post-acute coronary syndrome were more likely to take medications ( ACE-I, statins, anti-platelets ) then adhere to life-style modifications.
In a way, the studies show that there is hope. Post-ACS, we can help ourselves but changing our lifestyle ( less expensive and safer ). Similarly, there is dismay, that many would prefer the "pills" to helping themselves. There in lies the paradox of the modern man. Taking drugs is the easy way out. Helping yourself is tough. I will leave it to others.

1CARE for 1Malaysia, RESTRUCTURING OF THE MALAYSIAN HEALTH SYSTEM

I spend this Tuesday ( 2-3 rd Feb 2010 ) and Wednesday at the Holiday Villa Subang Jaya attending a MOH seminar on " 1CARE for 1Malaysia " 10th Malaysia Plan restructuring of the Malaysian Healthcare system. I would like to keep all Malaysians informed of the plans and what is coming ahead. I suspect that there maybe a snap election soon ( if the climate is right ), and should the present government win convincingly, they will push the plans. Otherwise, the plans may be shelved. So, in that sense, it is up to us. There again, it is not quite up to us ( if you know what I mean ). Anyway, lets roll on. I was invited as a representative of the Federation of Private Medical Practitioners Association of Malaysia.
At the meeting, it was well acknowledged that the present healthcare system that we are having, though there are problems, is by and large a good system that have served the country well. We spend a relatively ( 3.6% of GDP ) small amount and achieved almost world standard healthcare indices. But the powers that be, have decided that we must be " transformed into a high income economy", so the healthcare system must be " transformed and restructured". We were there o give our input ( sounds so nice, but it looks like their mind has been made up and we are there to window dress.
The MOH is proposing that basically we socialise healthcare. They are proposing that we create a social health insurance ( SHI ) scheme. All of us, citizens, will contribute. The government will contribute the majority ( the money from our direct taxation will go towards the National Health Insurance funds ) share. The rest, about 7% will be contributed by us. The employers maybe 4.5% and the employees, maybe 2.5%. ( the exact quantum has yet to be decided, but the employer/employee portion will be about 7% total ). This money will be administered by either the Ministry of Health or the Central Bank, and use to pay for healthcare. The GPs will be upgraded to Primary Care Physicians and they will be the frontliner and gatekeeper of the whole scheme. Local Primary Care Trust ( PCT ) will be set up in each locality. They will employ the Primary Care Physician and pay them. All of us will be registered with a Primary Care Physician. Anyone requiring medical help, will first be seen by his/her Primary Care Physician, who will assess and treat and only when necessary, refer for secondary care. All consult and treatment will be paid through the fund although some treatment may require co-payments.
This system proposed is very much like the UK NHS. The story goes that so and so went to UK and was very impressed with the NHS system, and felt that we should embrace it.
There is still much details to be iron out, but this is basically the gist of it. we were also told that all these nice plan will probably cosy the country about 6.2% of GDP.
Of course, our argument has always been that we have a good system, why change it. Why fix the furniture when it aint broken? Yes, there are problems with the present system, like long waiting list, inadequate coverage etc., but nothing that increasing the healthcare budget cannot fixed. If only they will retain our present good system, raise the healthcare budget to 6.2%. I believe that that will be better then all these socialised medicine, transformation and re-structuring.
At last, the powers that be must transform, and re-structure. The why always escapes us. Poor GPs, more problems on the way.

WASH AWARENESS WEEK. Feb 1st-Feb 7th 2010

I wonder how many of us are aware that Feb 1st-7th is WASH awareness week. WASH stands for " World Action on Salt and Health ", an organisation that creates public awareness of the dangers of salt intake and also lobbies government on salt levels in food.

Whenever I see patients in the risk group, especially those with hypertension or pre-hypertension, I always spend a considerable time to teach them that reducing salt intake, eating more greens and veges ( there is potassium salt in greens and veges ) help to reduce blood pressure. The evidence is in the studies with the DASH diet. What perhaps is not emphasized enough is that table salt and sauce is only a small portion of the salt that we all consume daily.

In ancients days when our forefathers were hunters, salt was a very convenient way to preserve the meat that they caught. It also added flavour. Nowadays, with refrigeration and packaging techniques, that need is not so important anymore, but producers found that salt was a cheap way to add weight to meat and also made the meat more palatable. So much of the salt that we now consume comes from the preservatives used in the food that we consume, be it meat or other food substances including corn flakes, and munchies.

Yet, we all know the evidence. By far, the best way to reduce hypertension and strokes is through a strategy of salt reduction, on an individual basis or community basis. Of course the classical off quoted study is that by Cook NR, Cutler JA, Obarzanek E, et al. entitled " Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observational follow-up of trials of hypertension prevention. BMJ 2007; 334:885. "

If that evidence is not strong enough, try this. In 1950, the Japanese government decided that there was too much salt being consumed in Japan. They were then consuming about 13.5gms of salt per individual per day. The government decided that for the next 10 years, they will reduced salt consumption in Japan to 12.1gms per day. This resulted, over the next 10years, in a stroke reduction of 80%. The same experience was reported in Finland, where salt intake was reduced by 30%, resulting in a stroke reduction rate of 80% again ( consistent isn't it ). All this with no increase in healthcare cost. Wonderful.

With these strong evidences, UK has formed CASH ( Consensus Action on Salt and Health ), subscribing to the same aim as WASH ( World Action on Salt and Health ). Perhaps in Malaysia we should form the MASH ( Malaysian Action on Salt and health ).

All that we need to do is to reduce our salt intake by 30%. We should see a stroke rduction of 80%. I estimate that in Malaysia, we consume about 13-15gms of salt daily, per person. We need to reach about 10-12 gms of daily salt consumption. I suppose we should begin by having compulsory food labelling, something which the Ministry of Health have been talking for along time.

We each need to know what we are taking in. It would be good if we can each consume 3-5 gms of salt a day. But this is difficult if we have been taking in 13 gms salt a day. A 30% reduction would be a good start to drop the incidence of hypertension and also strokes. In UK, the CASH has pushed the government to reduce salt intake for the average Englishmen by 10%. They are taking in less salt, on the average, compared to Asians ( UK about 9.5gms a day ).

Please pass the word around. Salt is an important cause of hypertension, and strokes. It would be too dramatic to say that " Salt kills " as salt has many important healthy bodily functions. we also cannot survive without salt. As everything in life, everything in moderation.

Please watch your salt intake. For starters, please be aware, that too much salt is bad for salt. Reducing salt intake by 30% is a good start.